From good to great physician: a critical ethnography based on patients' views.

The doctor-patient interaction (DPI) plays an important role in the way patients view physicians. Thus, response to the question of ''Who is a great physician?'' is related to DPI experiences of patients. The aim of this qualitative study was to explore patients' views regarding this subject. Based on critical ethnography in one educational hospital in Shiraz, Iran, the study was performed based on 156 clinical consultations, 920 hours of participant observations, and 6 focus groups with patients and their relatives. The results revealed that asymmetrical power relationships exist in this context. Based on the general views of participants and their recent DPI experiences, a great physician should be kind, empathetic, friendly, and a good listener. Considering the presence of an asymmetrical power relationships in this context, results showed that doctors do not participate in an active interaction. Based on sociological theories, it can be concluded that the concept of a great physician is not only limited to obligations as in the Parsonian view, but is also related to active communication between both sides which is presented in the critical view. Through active communication‎, asymmetrical power relationships can be reduced. Thus, if a physician wants to become a great physician, he/she must strengthen his/her humanistic dimensions and communicative skills alongside his/her medical skills.


Introduction
Numerous characteristics have been attributed to a good doctor. A good doctor is expected to be attentive, analytical, authoritative, accommodating, a good adviser, approachable, assuring, and etc. (1). However, it seems that a good doctor differs from a great doctor, but no deep scientific research has been conducted on this difference. Sir William Osler stated that the good physician treats the disease, while the great physician treats the patient who has the disease (2). This means that the great physician pays attention to the patient, while the good physician emphasizes the disease. A patient who was diagnosed with diabetes in 1960 stated that finding a great doctor is not easy, because some doctors do not listen to the patient (3). This means that a great doctor should be a good listener. Most doctors are great doctors in the eyes of the most patients (4). If a physician facilitates a great relationship and meets his/her patient's expectations, the patient feels that he/she is a great doctor. It seems that a high quality relationship is essential from patients' point of view. The doctor-patient interaction (DPI) is the main subject of the present study. Although DPI dates back to the Hippocratic Oath, it has been considered to be an important subject in the late 20 th century and onward (5,6). Overall, there is unified global view of characteristics of a great doctor. However, a patient's point of view toward a great doctor is contextual and it is also related to patient s' DPI experience.
Moreover, within each social and cultural context, there is a different view toward values and norms of medicineanddoctors'behaviors.Thismeansthatthe values of each society regarding the position of doctors and medicine are dependent upon that society'shistoricalcontext. In Iran, due to considerable social and behavioral changes, medicine has been dramatically commercialized, and as a result, the humanistic aspect of this trade is fading away. In addition, the present increase in individuals' knowledge is remarkable compared with two decades ago. This leads to a fluctuation in DPI, so that patient's expectation of a great physician is related to his/her experience of relationship. Therefore, the patient's DPI experience has an important influence on his/her view of a great physician. Generally, patients have expectations of their doctors. If a patient has a bad DPI experience, he/she will most likely start to judge doctors' behaviors based on his/her expectations. Here, the physician will be judged based on the characteristics that he/she does not have. In sociology there are two opposing views of DPI.
One is Parsons' theory which is also known as the sick role. This view has a functional approach; a doctor must perform his/her duties by curing patients until order returns to the social system (7, 8). The second view is a critical one, which has a humanistic outlook on DPI. In this view, DPI should not be distorted and there should be appropriate communication between doctors and patients based on a mutual understanding (9). Even though there have been an ample number of studies on the good physician in other countries, the great physician has been not been well understood. Because of this and due to extensive social changes in Iran, this study focused on the subject of the great physician. The goal of this study was to explore the characteristics of a great doctor according to patients' views and their recent experiences of DPI. Thus, the main question of the present study was: "who is a great physician?"

Method
This critical ethnographic study was conducted on patients admitted to an educational hospital in Shiraz, Iran, based on critical ethnography method. For data collection and analysis, triangulation method was applied. For this purpose, 156 clinical consultations, which were daily visits of admitted patients by faculty members and their students, were recorded digitally. Before this, verbal consent was obtained from each participant by researchers. In total, 156 consultations by 8 faculty members in cardiology, internal, and neurology wards were recorded digitally. In addition, 920 hours of participant observations were conducted by the researcher in all wards of the hospital. For participant observations, the researcher worked as a clinical supervisor by hiding his researcher identity. He observed the consultations, and in some cases, he conducted in-depth interviews with patients (n = 5). In these interviews, the patients were asked about their views of DPI, and data were recorded manually for analysis. In total, 6 focus group discussions were conducted with patients in internal, urology, general surgery, cardiac surgery wards, and the coronary care unit (CCU). Focus group research involves organized discussion with a selected group of individuals with the aim to gain information about their views and experiences of a topic. This research method is suitable for obtaining different perspectives about the same topic (10). After explaining the aims of the study to patients and their families, those who were willing to participate were enrolled in the focus groups (Table 1). Thequestionsinthefocusgroupswere:"How is the DPI in this hospital?"; "What is your opinion with regards to this type of DPI?"; and "From your point of view, who is a great physician?". The collected data were then transcribed. Data analysis was performed based on critical ethnography methodology which was introduced by Carspecken. He called this method "reconstructive analysis" (11). In this method, the cultural norms that shape people's behaviors are taken into consideration. These cultural norms which include values regarding people's behaviors are explored in order to interpret social contexts. Statements were analyzed according to three main validity claims; subjective, objective, and normative/evaluative. Subjective claims are those that represent perception of an interaction. Objective claims represent certain objects and events which occur during an interaction. Normative/evaluative claims are those which represent judgment (11,12). In this study, simultaneous to exploration of claims, the main themes of DPI were also explored. Themes that explained a great physician were discussed according to sociological DPI theory. The validity of this research was evaluated and confirmed through triangulation method (13, 14). In addition, trustworthiness was also confirmed in every phase of the analysis process, including preparation, organization, and reporting of the results (15,16). This study was conducted based on the ethical codes of the American Sociological Association (17). Based on these considerations and the ethical principles of research, all participants' names were kept confidential. Moreover, patients' privacy was taken into consideration. Furthermore, the study was approved by the Ethics Committee of Shiraz University, Iran.

Results
Our results showed that some patients were not satisfied with DPI, although most of them believed that their physicians were experts in their specialties. This finding was confirmed by other observations in our studies. Observations showed that some physicians did not visit their patients in the ward, In addition, the duration of the clinical consultations that took place in wards was very short. Of the 156 consultations that took place in different wards, some only took 1 minute. For instance, the resident would say that this patient is Ok and they would move on to the next patient without any form of communication. Therefore, the definition of a great physician is related to the quality of the relationships. Analyses of all data in triangulation method showed that a great physician must be kind, emphatic, friendly, and a great listener.

Kindness
Kindness is a theme that was heavily emphasized by the participants. This refers to patient's desire to see a doctor with at least a pleasant behavior such as a smile on his/her face.
Observer's Comments: During daily visits, rarely did any type of dialogue occur between the doctors and their patients. Doctors merely read reports, listens to medical students ' reports about the patient's condition, patient's vital signs, and paraclinical data such as magnetic resonance imaging (MRI), computerized tomography (CT) scan, or lab data, and what was prescribed. Under these conditions, if a patient asks a question, usually it is ignored or a simple answer is provided. After a few such encounters, the patient usually feels it is better not to ask any questions, as he/she feels that doctors are generally moody and they are not kind in the least.
Another issue that instigates this matter is when family daily visits are coming to an end and usually security guards force visitors to leave the room immediately with disrespect. This is what doctors want because they do not want to answer any questionsofthepatients'family. As validity claims show, kindness is a vital part of being a great physician, and it is any patient's expectation (Figure 1).

Empathy
Patients have physical and psychological issues and these disabilities may result in financial burden which puts more pressure on the family as a whole. Hence, they expect the physician to pay attention to every aspect of their illness. Their expectation is that doctors be empathetic towards their patients' circumstances and to put themselves in the place of their patients.  Figure 2).

Figure 2-Horizon analysis; possible validity claims of patients' view about a great empathetic doctor Friendliness
Friendliness refers to a relationship between doctors and patients, where both sides feel that they are communicating as friends. Being friendly means warm, face to face DPI while smiling, in a way that both sides feel as though they are interacting with their family members. If this form of interaction ever occurs, patients are surprised. Less foregrounded, less immediate: Emphaty means that the doctor puts him/herself in the patients' postion.

Possible objective validity
Quite foregrounded, quite immediate: The doctor had not explained the sitiuation before the family members became upset.
Less foregrounded, less immediate: The doctor did not empathize with his patient.

Possible normative calims
Less foregrounded, less immediate: Doctors have to sense patients' needs and problems.
Less foregrounded, less immediate: Doctors have to empathize with their patients. must allocate at least 5 minutes to each patient daily. In this way, the doctor will provide the patient with energy.] As figure 4 shows, doctors should be great listeners as well as great communicators. Thus, the patient can present his/her worries and concerns to the doctor, and the feedbacks show that these types of doctors are good listeners.

Discussion
Few studies have been performed on the characteristics of a great physician. Thus, the main question that was investigated in this study was: "what do patients demand from their physicians?" Although it seems that both technical and communicative skills are important (4), our findings showed that communicative skills are more important. The results showed that the participants demand that their physician to be kind, friendly, a good listener, and show empathy. Among all the participants, only two participants emphasized the importance of technical skills; a father of a girl with Tetralogy of Fallot (TOF) who was faced with complications after heart surgery and a woman with multiple sclerosis (MS) who was admitted with surgical problems. None of the other participants referred to technical skills. Patients may have been generally satisfied with the skills of doctors, although this could be due to the fact that

Possible Subjective Claims
Quite foregrounded, quite immediate: The doctor-patient friendship is proposed.
Less foregrounded, less immediate: DPI should be different from other forms of intraction.

Possible objective validity
Quite foregrounded, quite immediate: The doctor should act as a friend.
Less foregrounded, less immediate: The doctor-patient relationship should be based on friendship.
they were unaware of what great skills are or they were forced to refer to an educational hospital due to financial issues. Although this should be evaluated in future studies, the important point was that there was no significant dissatisfaction regarding skills. Based on our findings, it seems that a great physician in this context is someone who can communicate and interact well. From another aspect, it can be noted that patients in this hospital were faced with a specific form of interaction which was more linear and technical and refers to poor DPI. Instrumental interaction shows that doctors only interact with patients according to scientific findings, which is a deep rooted issue in biomedicine (5). In this approach, health and disease are defined in a simple and one-dimensional path.
Since the human body is a complex entity, the diagnosis of disease and treatment should be performed through a nonlinear method. Additionally, patients have souls which need dialogue, attention, and empathy. Among the four themes which were extracted, empathy plays a central role. This theme was emphasized more than others by the patients. Empathy is the capacity to understand or feel what an individual is experiencing, i.e., the capacity to place oneself in another's position (18). Many studies have shown the importance of empathy in clinical experiences (19)(20)(21). A study showed that empathy significantly influences patient satisfaction and compliance through mediating factors, such as perceived expertise, inter-personal trust, and partnership, and this can lead to patient satisfaction and compliance (19). Physicians who can empathize during visits through effective interactions can diminish irritation and hindrance and increase their therapeuticimpact (21).Itseemsthatdoctors'sense of empathy with their patients can facilitate a great relationship based on listening, kindness, and friendliness. In addition, these points lead us towards other new concepts in medicine which are called professionalism and patient-centeredness. In the concept of professionalism, it is an obligation to be a great listener, have empathy, and be kind which are considered to be important communication skills (22). Generally, we can say that our participants were in pursuit of a great physician rather than a good physician. Sir William Osler distinguished between a great physician and a good physician by stating: "The good physician treats the disease; the great physiciantreatsthepatientwhohasthedisease" (2). Accordingly, we believe that a great physician should not only pay attention to the patient's physical and mental problems in the context of the illness, but should also consider the patient's soul, family, and socio-economic status. Thus, a great physician always tries to cure patients holistically. It seems that the ultimate concern was to find a great doctor, rather than someone who can only cure the illnesses. Other dimensions of DPI can be discussed based on sociological theories. In this context, a great physician is someone who should comply with his/her professional obligations which is referred to a "functional view" in the Parsonian view (8). In this view, illness is defined as a social deviant, and the role of the physician is to return the society to a normal condition. In this approach, illness is considered to be a fundamental part of what may be called the motivational economy of the social system (8). Correspondingly, the therapeutic process must also be treated as part of that same motivational balance. This view presents the function of physicians as good physicians. Hence, a physician fixes the malfunctions of the social system with his/her medical knowledge. On the other hand, critical theory explores the quality of DPI from different view. According to communication action theory (23), in the context of this study, patients encountered a distorted relationship. Thus, there is a huge gap between doctors and patients. While, patients were in need of a doctor who communicates well, these physicians were mute without any active verbal and non-verbal communication. Thus, as Mishler has mentioned, there is a separation between the voice of modern medicine and the voice of patients' lifeworld (24). As a result, physicians do not recognize patients' expectations and desires. Therefore, doctors think that they are great doctors, while patients seek great doctors. This is a divergence condition which cannot lead to the two parties' mutual understanding. This claim was confirmed by other studies in this context. Results of a study by Sadati et al., based on the opinion of faculty members of Shiraz University Medical Sciences (Iran), showed that DPI in this context is distorted due to the disorganization of health care management and cultural barriers (25). Furthermore, it was shown that patients in the context of the study were faced with an unexpected interaction with unequal, unprofessional, instrumental, and non-cooperative features (26). Therefore, DPI in this context needs the communicative action approach in order to attain the great physician. Another view of critical theory showed the existence of power-knowledge relations between doctors and patients (27). According to this view, the doctor's domination can suppress patients. Thus, based on this view and our interpretation of the findings, patients seek a great physician in order to escape this suppression. Thus, when a doctor is kind, friendly and emphatic the possibility of suppression will decrease. Another study in a similar context showed different forms of domination and suppression in clinical consultations (28). Thus, it can be concluded that the desire for the good and great physician is related to communication between doctors and patients with the minimum level of unequal power relationships. One of the limitations of this study was the way in which the conversations were recorded. In fact, recording affects doctor's manner of consultation and dialogue. However, the researchers did not find another alternative for collection of the data. This is an important and basic restriction of qualitative studies, where the participants are aware of the recording and data collection, considering the fact that the researcher did not interfere with the natural course of the dialogues between the physician and the patient.

Conclusion
Being a good physician in general terms means knowing how to use appropriate medical techniques. Nevertheless, a great physician is someone who is not only a professional in using appropriate medical techniques, but who also has excellent communicational skills. The results of this study showed that in this context patients had experienced bad DPI. Thus, it is their desire for their physician to be kind, friendly, empathetic, and a good listener. Based on sociological theory, the results are more in favor of critical theory than functional theory. Thus, if a physician wants to become a great physician, he/she must strengthen his/her humanistic dimension and communicative skills in addition to his/her medical skills.